1. LARGE BOWEL OBSTRUCTION
&
ACPO

2. LARGE BOWEL OBSTRUCTION
INTERRUPTION IN THE PASSAGE OF LARGE
INTESTINAL CONTENTS

3. CLASSIFICATION OF LBO
Depending on nature of obstruction
Depending on the blood supply
Depending Upon Presentation
Depending Upon In Relation To Lumen

4. DEPENDING ON THE NATURE OF
OBSTRUCTION
DYNAMIC OBSTRUCTION
• Carcinoma colon
• Volvulus
• Diverticulosis
• Intussusceptions
• Adhesions
ADYNAMIC OBSTRUCTION
• Ogilvie’s syndrome
• Toxic mega colon
• Metabolic (hypokalemia)
• Post-op ileus
• Inflammatory disorder

5. DEPENDING ON THE BLOOD
SUPPLY
• Simple obstruction
• Strangulated obstruction
• Closed loop obstruction

6. DEPENDING UPON PRESENTATION
• Acute Obstruction : volvulus /obstructed
hernia
• Chronic obstruction : carcinoma colon /
diverticulosis
• Acute on chronic obstruction : ca colon

7. DEPENDING IN RELATION TO
LUMEN
• Outside the wall
• Inside the wall
• Inside the lumen-Foreign body,Fecal
impaction

8. DEPENDING IN RELATION TO LUMEN
OUTSIDE THE WALL
• Volvulus
• Hernias
• Tumour in adjacent organs
• Intra abdominal abscess
• Colonic obstructions
INSIDE THE WALL
• Carcinoma
• Inflammation
(diverticulosis,crohn’s
disease,LGV,schistosomiasis
,TB)
• Hirschsprung’s disease
• Ischemia
• Radiation
• Intussusceptions
• Anatomical stricture

9. MOST COMMON CAUSES OF LBO
• Colorectal cancer-65%
• Colonic volvulus-15%
• Diverticulitis-10%
• Others-10%
Hernia
Intussusceptions

10. MOST COMMON CAUSES OF LBO

11. PATHOGENESIS OF INTESTINAL
OBSTRUCTION
Changes proximal to bowel obstrucion
Changes at the site of obstruction
Closed loop obstruction
Changes in the bowel distal to obstruction
-Inactive and collapsed

12. CHANGES PROXIMAL TO BOWEL
OBSTRUCTION
Intestinal obstruction
Increased peristalsis
Vigorous peristalsis
If obstruction not relieved
Cessation of peristalsis

13. Cessation Of Peristalsis
Flaccid, Paralysed Bowel
Dilated Bowel

14. CHANGES AT THE SITE OF
OBSTRUCTION
Intestinal obstruction
Distension
Venous compression
Congestion and edema
Progressive arterial compromise

15. Loss of shineness, Blackish discolouration
Loss of peristalsis
Gangrene & Perforation
Bacteria and toxins migrate into peritoneum
Peritonitis

16. CLOSED LOOP OBSTRUCTION
Growth in the right colon with competent
ileocaecal valve
Pressure increases in the caecum
Stercoral ulcer in the caecum
Gangrene&Perforation
Fecal peritonitis

18. CLINICAL FEATURES OF LARGE BOWEL
OBSTRUCTION
• Symptoms :
Abdominal Distension
Abdominal Pain
Obstipation
Vomiting
Nausea / Anorexia

19. SIGNS OF LARGE BOWEL
OBSTRUCTION
• General signs of dehydration
• Abdominal findings :
Distension
Tympanitic Note
Rt To Lt Colonic Peristalsis
Borborygmi

20. SIGNS OF STRANGULATION
Features of septic shock : fever/hypotension/
renal failure/respiratory signs
Rebound tenderness
Guarding / rigidity
Absent bowel sounds
Constant pain / severe pain
Fever / tachycardia / leucocytosis

21. INVESTIGATIONS
• Blood : CBC / RBS / RFT / LFT / Electrolytes/ grouping
typing / ABG
• Imaging
1.upright chest x ray
2.supine / upright abdominal x ray
3.barium enema (single/ double contrast)
(gastrografin)
4.USG abdomen
5.CT with oral water soluble contrast / IV
contrast / rectal contrast
6.colonoscopy / sigmoidoscopy

22. MANAGEMENT OF LARGE BOWEL
OBSTRUCTION
Sun
should
not be
both rise
and set

23. PRINCIPLES
• Aspiration (ryles tube)
• Bowel care / blood transfusion
• Charts (temp,PR,RR,I/O,)/ critical care
• Drugs : antibiotics
• Exploratory laparotomy
• Fluids : IVF

24. PRINCIPLES OF EXPLORATORY
LAPAROTOMY
• Ideally done 6 – 8 hrs
• Long midline incision
• Check viability of bowel – if not viable resection
& anastomosis
• Adhesion – release
• Bands – divide
• Volvulus – untwist / resection
• Obstructed hernia – reduce
• Stricture – resection / stricturoplasty

25. FEATURES OF VIABLE BOWEL
• Normal peristalsis
• Normal peritoneal sheen is present
• Normal pulsation are visible or felt at
mesentery
• Normal pink colour is present

26. IN DOUBTFUL VIABILITY
• Warm saline soaked mop is placed over the
doubtful areas with 100% oxygen for 10 min
if colour become normal with peristalsis
Bowel is viable

27. PRINCIPLES OF EXPLORATORY
LAPAROTOMY
• Ideally done 6 – 8 hrs
• Long midline incision
• Check viability of bowel – if not viable resection
& anastomosis
• Adhesion – release
• Bands – divide
• Volvulus – untwist / resection
• Obstructed hernia – reduce
• Stricture – resection / stricturoplasty

28. COMPLICATIONS OF INTESTINAL
OBSTRUCTION
• Peritonitis
• Hypovolemia & septic shock
• Renal failure
• ARDS
• Intra abdominal abscess formation

29. POST SURGICAL COMPLICATIONS
• Pelvic abscess
• Subphrenic abscess
• Biliary or fecal fistula
• Burst abdomen
• Bands and adhesion
• Incisional hernia

30. MANAGEMENT OF MALIGNANT
LARGE BOWEL OBSTRUCTION
• Primary goal: Decompression of obstructed
segment to prevent perforation
• Secondary goal : Removal of the malignant
lesion

31. OBSTRUCTING LESION OF THE RIGHT
COLON
Stable patient:
Resection And Ileotransvese
Anastomosis In Single Stage

32. OBSTRUCTING LESION OF THE RIGHT
COLON
• Unstable patient & bowel perforation
1st
stage:
Resection Of Lesion But No Primary
Anastomosis
Terminal Ileostomy And Transverse
Colon Mucus Fistula
2nd
Stage:
Ileotransverse Anastomosis

33. OBSTRUCTING LESION OF THE RIGHT
COLON
Non - resectable lesion :
(Fixed To Posterior Abdominal Wall ,
Common Iliac Vessels)
Palliative:
Ileotransverse Anastomosis
Caecosigmoidostomy

34. OBSTRUCTING LESION OF THE
TRANSVERSE COLON
• Treatment :
Extended Rt Hemicolectomy + Removal Of
Whole Omentum, Transverse Colon+
Ileocolic Anastomosis (Distal Transverse
Colon Or Proximal Descending Colon)

35. OBSTRUCTING LESIONS OF THE LEFT
COLON
Treatment options:
Three stage operation- Unstable Patient
Two stage operation- Unstable Patient
Single stage operation- Stable Patient
Sub total colectomy and ileorectal anastomosis
- Unhealthy proximal colon

36. THREE STAGE OPERATION
Transverse colostomy
After 3 – 6 weeks
Elective resection of tumour with an anastomosis
After 8 weeks
Colostomy closure

37. TWO STAGE OPERATION
Hartmann’s Operation
After Six weeks
Restoration Of Bowel Continuity

38. SINGLE STAGE OPERATION
Stable Patient:
Left Hemicolectomy & Colorectal
Anastomosis

39. UNRESECTABLE LESION
External diversion: colostomy
Internal diversion: caecosigmoidostomy

40. COLONIC STENTS
Decompression Of The Obstruction
Emergency Situation Elective Setting

41. COLONIC STENTS

42. COLONIC VOLVULUS
SIGMOID VOLVULUS – 53%
CECAL VOLVULUS - <42%
TRANSVERSE COLON-3%
SPLENIC FLEXURE-2%

43. SIGMOID VOLVULUS

44. SIGMOID VOLVULUS
• Predisposing factors
Long mesentery of the pelvic colon
Narrow attachment at the base
Long, redundant and pendulous sigmoid
Loaded colon due to residue diet
Diverticulitis with band/adhesions

45. CLINICAL FEATURES OF SIGMOID
VOLVULUS
• Acute sigmoid volvulus
Abdominal pain
Absolute constipation
Abdominal distension-tympanitic abdomen
Tyre like feel
Features of peritonitis

46. CHRONIC RECURRENT SIGMOID VOLVULUS
• Clinical features
Recurrent left lower abdominal pain
Abdominal distension
Relieved by passage of large amount of flatus

47. INVESTIGATIONS Contrast Enema
Bird’s beak sign
Bird of prey sign
Ace of spade sign
CT Abdomen
Whirl pattern
X- Ray Abd Erect
Omega sign
Coffee bean sign
Bent inner tube
sign

48. SIGMOID VOLVULUS
INTRA-OPERATIVE INTRA-OPERATIVE

51. MANAGEMENT
• Non operative management
Resuscitation Endoscopic Decompression Using
Flatus Tube/Sigmoidoscopy/ Flexible Colonoscopy
If Obstruction Relieved If Not
Elective Surgery Emergency
After One Week Laparotomy

52. Non operative management

53. NON OPERATIVE MANAGEMENT-FLATUS TUBE

54. OPERATIVE MANAGEMENT
If Bowel Is Gangrenous
Single Stage- Resection And End To End
Anastomosis
Hartmann’s Operation
Exteriorisation Of Bowel
If Bowel Is Not Gangrenous
Single Stage- Resection and End To End
Anastomosis
Sigmoidopexy

55. COMPOUND VOLVULUS
Ileo SIgmoId KnottIng
Due To Presence Of Long Pelvic Mesocolon
Allows The Ileum To Twist Around The
Sigmoid Colon
Presents As Acute Intestinal Obstruction
X-ray : Dilated Both Ileal And Sigmoid Loops
Treatment: Resuscitation Decompression
f/b Resection And Anastomosis or
Exteriorisation Of Bowel

56. COMPOUND VOLVULUS

57. ILEO SIGMOID KNOTTING

58. CECAL VOLVULUS
• Due to failure of fixation of the ileal and caecal
mesentery to the posterior abdominal wall
• Predisposing factors:
Previous surgery
Pregnancy
Obstructing lesion of left colon
Malrotation

60. INVESTIGATIONS • Plain Xray Abdomen Erect
Comma Shaped Dilated
Ceacum In Left Upper
Abdomen
Single Long Fluid Level
Dilated Small Bowel Right Of
The Distended Caecum
Contrast Enema:
Tapering Of
Ascending Colon
CT Abdomen:
Dilated Caecum
With Fluid Level

61. CAECAL VOLVULUS

62. CAECAL VOLVULUS

63. MANAGEMENT
Right hemicolectomy with primary
anastomosis
Caecostomy/Caecopexy
Endoscopic decompression/derotation not
advisable

64. INTUSSUSCEPTION
• Defined as the Invagination of one segment of
intestine into the adjacent segment
• Types:
Antigrade:
Simple: Ileocolic, ileoileal, colocolic
Compound: Ileoileocolic
Retrograde:
Jejunogastric intususception

65. Ileocolic-iss

66. PARTS OF INTUSSUSCEPTION
Intussuscipiens:Distal bowel which receives
the intestine
Intussusceptum:Proximal bowel which enter
into distal segment
Apex:Is the part which advances
Lead point

67. CAUSES OF INTUSSUSCEPTION
In Infants
Change in diet during
weaning period
Upper respiratory tract viral
infection
In Adults
Intestinal polyps
Submucous lipomas
Meckel's diverticulum
Carcinoma
Leomyoma of intestine
Purpuric submucosal
haemorrhages-HSP

68. CLINICAL FEATURES OF
INTUSSUSCEPTION
Symptoms
Severe cramping abdominal
pain
Vomiting
Red current jelly stool
Signs
Sausage shaped mass in
umbilical region
Right iliac fossa empty
Step ladder peristalsis
Features of peritonitis
PR shows blood stained
mucus-Red current jelly

69. INVESTIGATIONS PlainX-ray:
Multiple air fluid levels
Barium enema:
Claw Sign Or
Coiled Spring Sign Or
Meniscus Sign
Ultrasound abdomen :
– Target sign
– Psuedokidney sign
– Bull’s eye sign
Doppler Study :
To Check Blood
Supply Of Bowel
It Shows Mass With
Doughnut Sign
CT Abdomen
 Target sign

71. MANAGEMENT
• Non operative management:
Hydrostatic reduction
– Contrast enema
– Air enema
– Warm saline
Contraindications:
Perforation
Profound shock and
known pathological lesion

72. SURGICAL MANAGEMENT OF ISS
• Laparotomy and reduction of intussusception
milking method
If Reduction possible If not possible
check the viability & Resection and
suture terminal ileum anastomosis
to ascending colon

74. SURGICAL MANAGEMENT OF ISS
• Laparotomy and reduction of intussusception
milking method
If Reduction possible If not possible
check the viability & Resection and
suture terminal ileum anastomosis
to ascending colon

75. ACUTE COLONIC PSEUDO
OBSTRUCTION-ACPO
• Defined as Massive Colonic Distension In The
Absence Of Mechanically Obstructing Lesion
• Etiology:
Primary pseudo-obstruction
• Familial visceral myopathy
• Sporadic visceral myopathy

76. SECONDARY PSEUDO
OBSTRUCTION
Smooth muscle disorders:
Collagen vascular disorders
Scleroderma,
Dermatomyositis
Muscular dystrophy- Myotonic dystrophy
Amyloidosis
Neurological disorders
–Chaga's disease
–Parkinsonism

77. SECONDARY PSEUDO
OBSTRUCTION
Drugs- Phenothiazines, Tricyclic
antidepressants and opioids
Metabolic-Uremia, Hypokalemia, Diabetes,
Myxoedema, Hypoparathyroidism
Viral infections

78. CLINICAL FEATURES OF ACPO
Medically ill patient suddenly develops
abdominal distension
Tympanitic abdomen
Not tender
Bowel sounds present

79. INVESTIGATIONS
• Plain Xray Abdomen Erect :
Shows Distension Of Colon
• Water Soluble Contrast Enema:IOC
Differentiates ACPO From Mechanically
Obstructing Lesions
• Colonoscopy Not Advisable

80. Plain Xray Abdomen Erect-acpo

81. MANAGEMENT
Non operative:
– Injection Neostigmine 2.5mg iv over 3 minutes
– Epidural anaesthesia
– Colonoscopic decompression
Operative:
Emergency Laparotomy
– If there is no ischemia or perforation-loop
colostomy
– If there is ischemia or perforation-Resection and
ileostomy with mucus fistula

82. THANK YOU
THANK U